Health Affairs Examines Impact of ACA on Two Vulnerable Groups: Americans with HIV/AIDS and Jail-Involved Individuals3/6/2014

Health Affairs' March issue explores how the Affordable Care Act (ACA) could affect two key sectors of the population with unique public health needs--those living with HIV/AIDS and people who have recently cycled through local jails.

When it comes to HIV treatment, timing is everything. Dana P. Goldman of the University of Southern California and coauthors modeled HIV transmission and prevention based on when HIV-positive individuals started combination antiretroviral treatment (cART). They estimated that from 1996-2009, early treatment initiation in the US prevented 188,700 HIV cases and avoided $128 billion in life expectancy losses. They highlight treatment at "very early" stages (when CD4 white blood cell counts are greater than 500, consistent with current treatment guidelines in the US) as responsible for four-fifths of prevented cases. Early treatment both reduces morbidity and mortality in people living with HIV/AIDS, and decreases the transmission of the disease to the uninfected. The authors conclude that early treatment has clear value for both HIV-positive and HIV-negative populations in the US.

Early treatment of HIV can add valuable years to life--if guidelines are followed. John A. Romley of the University of Southern California, Los Angeles, and coauthors analyzed the effects on life expectancy of people initiating combination antiretroviral therapy at early stages of the disease, when CD4 white blood cells are 350 or higher. In recent years, US treatment guidelines have been revised to recommend treatment at all CD4 counts. The authors found an average gain in life expectancy of 6.1 years for people who initiated therapy when CD4 counts were 350 to 500, and 9.0 years when initiating with CD4 counts above 500. They estimate the value of survival gains from early initiation from 1996 to 2009 at $80 billion, with each life year valued at $150,000. The authors found a much higher mortality risk among HIV-positive individuals if treatment was initiated when CD4 counts were less than 350: 28 percent higher versus when counts were 350 to 500; 1.16 times higher than if started when counts were greater than 500. The earliest treatment initiators--following the current US treatment guidelines--could expect to live 39.7 years. The authors point to the importance of treatment guideline adherence and to investment in the underlying scientific investigation that results in their development.

The ACA could help the fight against HIV/AIDS, particularly if more states expand Medicaid.Zachary Wagner and colleagues at the University of Southern California, Los Angeles, modeled the effects of the ACA and found that by 2017, an additional 466,153 people will be tested for HIV and 2,598 new cases would be diagnosed. They also found that among the newly insured under the ACA, the population of HIV-positive people who were unaware of their status would decline by 22 percent. The authors point to evidence that gaining health insurance can improve testing rates, and that more generous Medicaid benefits can increase the use of treatment by HIV-positive individuals, both important contributors to prevention efforts. They conclude that if all states expand their Medicaid programs, the effects could be 30 percent larger and recommend that state leaders consider ways to expand insurance coverage to those who remain uninsured.

The cluster of papers on jails and health reflects ongoing concerns about how to manage the health needs of a population with higher rates of communicable diseases, mental illness, substance abuse, and many chronic conditions--and what the return of "jail-involved" individuals to communities will bring as Medicaid expands in many states and the ACA provision ensuring care to them becomes a reality.

Featured papers include:

• Marsha Regenstein and Sara Rosenbaum of The George Washington University focus on continuity of care and the use of electronic health records for people transitioning out of jails in What The Affordable Care Act Means For People With Jail Stays
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• In The Critical Link Between Health Care And Criminal Justice, James S. Marks of the Robert Wood Johnson Foundation and Nicholas Turner of the Vera Institute of Justice analyze the opportunities presented through Medicaid expansion to bring the jail-involved into the mainstream health care system.

• Josiah D. Rich of Brown University and Miriam Hospital in Providence, Rhode Island, and coauthors, present recommendations for improvements within and outside of the correctional system to better care for jail-involved individuals in How Health Care Reform Can Transform The Health Of Criminal Justice-Involved Individuals.

Support for the HIV/AIDS articles included grants from Precision Health Economics and the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California. The Robert Wood Johnson Foundation provided support for Health Affairs' first-ever series of papers on jails and health.